Despite many initiatives to assure food access, and growing economies, high levels of undernutrition persist in much of Asia. It is increasingly suggested that much of this ‘Asian enigma’ can now be explained by open defecation (OD) combined with population density. The Institute of Development Studies (IDS) has recently produced a working paper that seeks to reframe undernutrition to encompass the typically neglected and often sub-clinical faecally-transmitted infections (FTIs), including environmental enteropathy (EE), other intestinal infections, and parasites. They argue that diarrhoea is the “tip of a much larger sub-clinical iceberg”.

While the scope of the paper is worldwide, the major focus is on India which has about one third of the stunted children in the world, around 60% of the world’s OD, and a wealth of very recent relevant research. How OD and FTIs, poverty and undernutrition reinforce each other is examined in a case study on India.

The working paper has three purposes: to examine how OD, lack of sanitation and hygiene, and FTIs contribute to stunting; to shed light on why this has been a blind spot; and to present new inclusive categories and concepts (the FTIs, see above, and the 5 As, see below) for reframing how undernutrition is perceived, analysed and acted on. The authors highlight that while other countries make rapid progress towards becoming OD free, India remains obstinately stuck, making undernutrition in India one of the great human challenges of the twenty first century. The paper concludes by exploring practical implications of this reframing for research, teaching and training, as well as policy and practice.

The 5 A’s: the first two A’s – availability and access – are oral, about food intake, while the last three As – absorption, antibodies and allopathogens – are novel categories, anal and internal, about FTIs and what happens inside the body.